Will a Preterm Babies Perforated Bowel Heal Without Surgery
Gastroenterol Res Pract. 2016; 2016: 6134187.
Bowel Perforation in Premature Infants with Necrotizing Enterocolitis: Risk Factors and Outcomes
Lingling Yu
aneSection of Neonatology, Children's Hospital of Soochow University, Suzhou 215003, China
Jianmei Tian
iiDepartment of Communicable diseases, Children'south Hospital of Soochow Academy, Suzhou 215003, Communist china
Xingli Zhao
aneDepartment of Neonatology, Children's Infirmary of Soochow University, Suzhou 215003, China
Ping Cheng
oneSection of Neonatology, Children'southward Hospital of Soochow Academy, Suzhou 215003, Mainland china
Xiaoqian Chen
oneSection of Neonatology, Children's Infirmary of Soochow University, Suzhou 215003, China
Yun Yu
1Department of Neonatology, Children'due south Hospital of Soochow Academy, Suzhou 215003, China
Xiaochun Ding
1Section of Neonatology, Children's Hospital of Soochow University, Suzhou 215003, People's republic of china
Xueping Zhu
1Department of Neonatology, Children's Infirmary of Soochow University, Suzhou 215003, People's republic of china
Zhihui Xiao
1Department of Neonatology, Children'southward Hospital of Soochow University, Suzhou 215003, China
Received 2016 Jan 30; Revised 2016 April 18; Accustomed 2016 May 17.
Abstract
We aim to determine risk factors and clinical outcomes for bowel perforation in premature infants with NEC. We analyzed clinical information of 57 cases of premature infants with NEC at our NICU betwixt Jan 2010 and Dec 2012. Based on the presence of bowel perforation, we divided these infants into two groups: perforated NEC grouping (n = ten) and nonperforated NEC group (n = 47). We compared general information, clinical characteristics, and laboratory findings between groups. The perforated NEC grouping, compared to the nonperforated NEC group, had significantly lesser gestational age, lower birth weight, higher prevalence of apnea, mechanical ventilation, sepsis and shock, lower blood pH, higher levels of blood glucose, abnormal WBC count and thrombocytopenia, and elevated CRP (all P < 0.05). Moreover, the perforated NEC grouping had significantly longer durations of fasting and TPN usage, higher incidences of EUGR and cholestasis, longer elapsing of antibiotics, higher frequency of advanced antibiotics use, and poorer prognosis than the nonperforated NEC group (all P < 0.05). Bowel perforation in premature infants with NEC was associated with multiple risk factors. Early on identification of some of these risk factors in premature infants with NEC may help implement early on intervention to reduce the incidence of bowel perforation and thereby improve the prognosis.
1. Introduction
Necrotizing enterocolitis (NEC) is one of the devastating diseases in premature neonates [1–4]. A high incidence of NEC (7%) and related mortality (20–30%) has been reported in very depression birth weight (VLBW) infants [i], and, in our infirmary, the incidence of NEC was 5.54% [5]. Bowel perforation is a life-threatening complication of NEC in premature infants [6]. This complication is associated with mortality equally loftier as 76% [7] and long-term complications amongst survivors, such every bit brusque bowel syndrome, growth and developmental retardation, and adverse neurological upshot [eight].
Linder et al. [ix] have constitute bowel perforation in NEC associated with postnatal age, abdominal distension, metabolic acidosis, college blood glucose, and elevated liver enzymes. In extremely LBW infants, Wu et al. [x] establish that bowel perforation was associated with thrombocytopenia, elevated C-reactive protein (CRP), and anemia. However, risk factors for bowel perforation in neonates with NEC are not well characterized.
In the electric current report, we aimed to decide potential run a risk factors and clinical outcomes of bowel perforation in premature infants with NEC.
two. Methods
two.i. Written report Population
Nosotros used Bell's staging criteria [eleven] to define NEC stages: stages IA and IB for suspect NEC, stage II for definite NEC, and phase III for advanced NEC. Nosotros identified 57 cases of NEC (stage 2 and above) in premature infants admitted to the neonatal intensive care unit of Children's Hospital of Soochow University (Suzhou, Cathay) from January 2010 to Dec 2012. We excluded 46 cases with incomplete clinical information and those with known digestive tract malformation. The Institutional Review Board of the Children'south Hospital approved the study. Informed consent was obtained from the parents.
The diagnosis of bowel perforation in NEC cases was based upon clinical manifestation in combination with findings on dynamic abdominal X-ray studies and at surgery, such as pneumoperitoneum [12]. In seven cases, perforation was diagnosed by 10-ray and in 3 cases perforation was identified at surgery. Based on the presence of bowel perforation, we divided the cases into two groups: perforated NEC group (n = 10) and nonperforated NEC grouping (n = 47). The treatment of NEC included fasting, gastrointestinal decompression, third-generation cephalosporins, and total parenteral nutrition (TPN).
2.2. Clinical and Laboratory Examinations
We collected data on demographical information, clinical characteristics, perinatal factors, and complications. Data included gender, gestational age, birth weight, 5-infinitesimal Apgar score, maternal diseases and conditions during pregnancy (pregnancy-induced hypertension or diabetes, premature rupture of membranes, placenta previa, and placental abruption), fetal distress, delivery mode, singleton or twin pregnancy, age of onset of NEC (days), time for the first breastfeeding, rapidity of increase of milk intake, neonatal respiratory distress syndrome (RDS), neonatal pneumonia, built heart affliction (CHD), sepsis (early on-onset sepsis defined every bit less than postnatal 72 hours; late-onset sepsis defined as later than postnatal 72 hours), apnea, intracranial hemorrhage (ICH), shock (infectious shock), blood transfusions, and mechanical ventilation. We also nerveless information on clinical symptoms including abdominal distension, airsickness, and bloody stools and extrauterine growth retardation (EUGR) at discharge (EUGR defined as the weight calculated on the basis of the right gestational age less than their peers beneath the 10th percentile at discharge). Laboratory data included white claret cell count (WBC, aberration defined every bit <5.0 or >20 × 109/L), platelet count (thrombocytopenia defined as <100 × 10ix/50), CRP (aberration defined as >8 mg/L), arterial blood gas parameters, and blood glucose levels (hyperglycemia defined as blood glucose > seven.0 mmol/Fifty).
Score for Neonatal Astute Physiology-II (SNAP-II) and SNAP-Perinatal Extension-2 (SNAPPE-II) scoring systems [13] were estimated for all NEC cases inside 24 hours of life. The simplified version of the 2001 SNAP-II scoring system [13] included six objective measures, namely, average blood pressure, the lowest body temperature, PO2/FiO2 ratio (oxygenation index), multiple twitches, urine book, and the everyman serum pH. These measures plus nascence torso mass, Apgar score, and minor for gestational age (SGA) comprised the SNAPPE-II scores.
ii.3. Statistical Analysis
Data were analyzed by using SPSS v20 statistical software package (SPSS, Inc., Chicago, IL, USA). Unremarkably distributed continuous data were expressed as mean ± standard departure (SD), and differences between groups were tested past t-test. Continuous data which were not normally distributed were expressed as median and interquartile range and tested past using rank examination for differences between groups. Numerical data were expressed past number and percentage within groups and tested past using the chi-square examination. When theoretical frequency was <one in the contingency tabular array, Fisher's verbal probability method was used, and when theoretical frequency was ≥1 and <five, continuity correction was carried out. A P value <0.05 was considered as statistically significant.
three. Results
Tabular array 1 shows general characteristics of NEC infants with and without bowel perforation. Among the total 57 cases, 18 were male and 39 were female. Among the NEC group with perforation, 4 cases gave upward treatment (all the 4 cases died according to our follow-upward by phone call), while in the NEC group without perforation, 9 cases gave up treatment due to economic reasons (6 died and iii survived) (at the fourth dimension of the decision to withdraw support, the infants were moribund and the prognosis was futile). The perforated NEC group (n = 10), compared to the nonperforated NEC group (due north = 47), had a significantly lesser gestational age and lower nascency weight (all P < 0.05). There were no meaning differences regarding the distribution of gender, SGA, twin pregnancy, Apgar score, fetal distress, cesarean section, or maternal diseases between 2 groups (P > 0.05). In addition, nosotros did not observe pregnant differences with respect to SNAP-2 and SNAPPE-II scores between groups.
Tabular array 1
General characteristics in NEC infants with and without bowel perforation.
| Perforated NEC group (n = x) | Nonperforated NEC group (n = 47) | P | |
|---|---|---|---|
| Gestational age (weeks)a | 31.52 ± two.31 ∗ | 33.49 ± 2.57 | 0.03 |
| Body weight (g)a | 1550 ± 550.25 ∗ | 1967.87 ± 518.98 | 0.03 |
| Maleb | 5 (50.00) | 30 (63.83) | 0.65 |
| SGAb | 3 (30.00) | 7 (xiv.lxxx) | 0.49 |
| Twin pregnancyb | v (50.00) | 13 (27.lx) | 0.31 |
| Low Apgar scoreb,c | 1 (10.00) | five (10.60) | 1.00 |
| In utero fetal distressb | 1 (10.00) | iii (6.xxx) | 0.55 |
| Cesarean departmentb | 6 (60.00) | 30 (63.80) | ane.00 |
| Maternal diseasesb | four (40.00) | 17 (36.i) | 1.00 |
| SNAP-IIa | 8.38 ± four.75 | viii.14 ± half-dozen.83 | 0.09 |
| SNAPPE-2a | 12.88 ± 9.02 | 13.05 ± 9.96 | 0.96 |
The perforated NEC group had significantly higher prevalence of apnea, sepsis, and shock and a more frequent utilization of mechanical ventilation than nonperforated NEC group (Table 2). At that place was one example of early-onset sepsis and 4 cases of late-onset sepsis in the perforated NEC grouping and at that place was no example of early-onset sepsis and 4 cases of late-onset sepsis in the nonperforated NEC group. Shock was establish in three cases of perforated NEC grouping and in 1 case of nonperforated NEC group. Concomitance of sepsis and shock was found among 3 cases in the perforated NEC group and one instance in the nonperforated NEC group. NEC onset historic period, time for the first enteral feeding, speed of increment of milk intake, the distribution of main diseases, RDS, neonatal pneumonia, intestinal distension, airsickness, bloody stools, CHD, claret transfusion, and ICH were not significantly different between groups (P > 0.05).
Table ii
Clinical characteristics in NEC infants with and without bowel perforation.
| Perforated NEC grouping (n = 10) | Nonperforated NEC grouping (n = 47) | P | |
|---|---|---|---|
| Onset age (d)a | x.0 (7.50–22.25) | 7.0 (ii–14) | 0.40 |
| Time for the first enteral feeding (d)b | 3.8 ± 3.16 | 5.8 ± 3.48 | 0.08 |
| Speed of the increment of milk intake (cc/kg/d)b | 4.20 ± 3.65 | 7.02 ± 6.48 | 0.07 |
| Abdominal distensionc | 10 (100.00) | 35 (74.40) | 0.17 |
| Airsicknessc | 6 (threescore.00) | nineteen (40.twoscore) | 0.43 |
| Stool RBCsc | 3 (thirty.00) | 18 (38.30) | 0.89 |
| CHDc | 4 (40.00) | 9 (19.10) | 0.31 |
| Sepsisc | iv (xl.00) ∗ | iv (8.50) | 0.04 |
| Apneac | 6 (60.00) ∗ | seven (14.80) | <0.01 |
| ICHc | ii (20.00) | 2 (iv.20) | 0.xiv |
| Stuporc | 3 (30.00) ∗ | 1 (two.10) | 0.02 |
| RDSc | 3 (30.00) | 7 (14.lxxx) | 0.49 |
| Neonatal pneumoniac | 5 (l.00) | 22 (46.lxxx) | one.00 |
| Blood transfusionc | 4 (40.00) | 6 (12.seventy) | 0.12 |
| Mechanical ventilationc | 7 (seventy.00) ∗ | xiv (29.70) | 0.04 |
With regard to laboratory tests (Tabular array three), all the data were obtained during the course of NEC and before the perforation; the perforated NEC grouping had a lower arterial blood pH and higher blood glucose levels than nonperforated NEC group. Meanwhile, the likelihood of abnormal WBC count, thrombocytopenia, and elevated CRP was significantly higher in the perforated NEC group compared to nonperforated NEC group.
Table three
Comparing of laboratory tests in NEC infants with and without bowel perforation.
| Perforated NEC group (n = x) | Nonperforated NEC group (n = 47) | P | |
|---|---|---|---|
| pH valuea | 7.27 ± 0.12 ∗ | vii.37 ± 0.x | 0.02 |
| Abnormal WBC countb,c | six (60.00) ∗ | nine (xix.15) | 0.02 |
| Thrombocytopeniab | 7 (70.00) ∗ | 4 (8.51) | <0.01 |
| Elevated CRPb,d | seven (70.00) ∗ | xiii (27.60) | 0.03 |
| Blood glucose level (mmol/Fifty)a | 7.80 ± five.40 ∗ | three.lx ± 1.74 | 0.04 |
Amongst the NEC perforated group, ii cases died, four gave up treatment, and the remaining 4 cases were treated by surgery. The perforated NEC group, compared to the nonperforated NEC group, had significantly longer durations of fasting, TPN days, and antibiotics, higher incidences of extrauterine growth restriction (EUGR) and cholestasis, and higher frequency of antibiotics upgrade (Table 4).
Tabular array 4
Treatments and complications in NEC infants with and without bowel perforation.
| Perforated NEC group (northward = 4) | Nonperforated NEC grouping (northward = 37) | P | |
|---|---|---|---|
| Duration of fasting (d)a | 17.25 ± two.21 ∗ | 8.21 ± 1.29 | <0.01 |
| Apply of carbapenem antibioticsb | 4 (100.00) ∗ | 6 (16.21) | <0.01 |
| Duration of antibiotic treatment (d)a | 21.00 ± 3.37 ∗ | 10.39 ± 3.40 | <0.01 |
| Gastrointestinal decompressionb | 4 (100.00) | 17 (45.94) | 0.xiii |
| Elapsing of TPN use (d)a | 37.5 ± eight.10 ∗ | 22.21 ± 7.53 | <0.01 |
| Cholestasisb | 3 (75.00) ∗ | 5 (13.51) | <0.01 |
| EUGRb | iv (100.00) ∗ | xiii (35.10) | <0.05 |
During the clinical follow-up, all 4 cases in the perforated NEC group who gave upwards treatment died, and 2 of the four cases who underwent surgery had growth and development retardation. In the nonperforated NEC group, ane case died, 9 gave up treatment (6 died and 3 survived past the telephone follow-upwards), and eight of the other 37 cured cases showed growth and development retardation. The cure rate and mortality betwixt the groups during follow-up were significantly (P < 0.05) different (Figure 1).
Clinical outcomes of NEC infants with and without bowel perforation. ∗ P < 0.05 compared to the nonperforated NEC group. "Cured" means complete functional recovery to a healthy state, while "Improved" means partial functional recovery with symptoms ameliorated, while some organ dysfunctions may remain.
4. Discussion
In this report, nosotros found that bowel perforation in premature infants with NEC was associated with multiple hazard factors, such as lesser gestational age, lower nascence weight, apnea, and sepsis. In addition, the perforated NEC group had higher prevalence of abnormal WBC count, thrombocytopenia, elevated CRP, and blood glucose levels than nonperforated NEC group. The bowel perforation was also associated with unfavorable prognosis. Previously, earlier postnatal age at NEC occurrence and lower birth weight were identified every bit high-risk factors for bowel perforation in NEC by Linder et al. [9].
NEC, particularly complicated with bowel perforation, is the leading crusade of deaths in preterm neonates [viii]. Some studies have suggested a rapid increase of milk intake, asphyxia, maternal diseases, CHD, and blood transfusion as high-adventure factors for NEC in premature neonates [14, xv]. All the same, it is unclear whether these factors influence bowel perforation in infants with NEC. We found no meaning differences with respect to the aforementioned factors betwixt two groups.
Apnea, sepsis, shock, and mechanical ventilation were associated with bowel perforation in NEC in the nowadays study. Although a causal relationship cannot exist merely established past this report, the relation betwixt these factors and bowel perforation is biologically plausible. Apnea can result in hypoxia: in the hypoxic state, one of the compensatory responses which develops is intestinal vascular contraction, leading to abdominal ischemia and hypoxia, intestinal mucosal injury, and intestinal bacterial translocation and finally to NEC [16–18]. Shock can bear on the circulation and aggravate the abdominal ischemia injury. Infection induces microvascular platelet-leukocyte aggregates past activating inflammatory factors, and clogged blood flow increases intestinal mucosal damage which in turn leads to abdominal necrosis and perforation. Apnea, rapid advancement of milk intake, and infection were reported as the iii about pregnant factors for NEC [xix]. Sudden onset of tachycardia and shock in preterm neonates with NEC often warns the impending perforation [20]. Mechanical ventilation was also reported as a risk cistron for perforation requiring surgical intervention in infants with NEC [21]. Our written report institute significantly college prevalence of apnea, sepsis, stupor, and mechanical ventilation in NEC cases with bowel perforation compared to those without. Therefore, attention should be paid to these chance factors in infants with NEC. An acceptable fasting fourth dimension, careful monitoring of abdominal amplification, and vomiting after feeding are essential to forestall bowel perforation.
NEC usually manifests as abdominal distension, vomiting, claret in stools, and feeding intolerance. Linder et al. [9] reported abdominal amplification as a high-hazard factor for bowel perforation in NEC. In our study, all x NEC cases with bowel perforation had intestinal distension, while only 74% (35/47) of the NEC cases without bowel perforation had this finding. In NEC, progression of abdominal distention should exist closely monitored and, when necessary, a dynamic abdominal vertical obviously radiograph may exist performed. At that place were higher rates of pneumoperitoneum and fixed intestinal loop on abdominal radiographs in NEC grouping requiring surgery compared to those who did not require surgery [21]. Plain intestinal radiographs are standard imaging modalities of choice for evaluation of patients with NEC: they must be considered at any bespeak of acute clinical deterioration. This investigation is critical considering findings may exist helpful for better patient management and betoken the need of surgical intervention [22].
The present report showed that NEC cases with bowel perforation were more probable to exhibit an abnormal WBC count, thrombocytopenia, meaning increase of CRP, and relatively low blood pH compared to those without bowel perforation. Inflammation has been implicated equally the final common pathway of NEC. WBC count and CRP are important indicators of the inflammatory response, while thrombocytopenia is a sign for severe infection.
Srinivasjois et al. [23] and Wiwanitkit [24] suggested that a significant reduction in platelet count is parallel to the progression of NEC, and, for neonates on handling, an increasing CRP frequently implies the occurrence of bowel perforation. Linder et al. [nine] showed a close relation between the relatively low blood pH and bowel perforation in NEC. Moreover, our finding of higher blood glucose levels in NEC cases with bowel perforation compared to those without bowel perforation agrees with previous information indicating that high blood glucose level is a risk gene for poor prognosis in NEC [ix].
SNAP scoring system, including the full version consisting of 27 items of physiological indices [25] and two simplified versions (SNAP-II and SNAPPE-II) [13], is a validated tool to evaluate the health condition of neonates. The higher the SNAP scores, the worse the disease. Bonnard et al. [26] identified the utility of SNAPPE-Ii to guide the treatment of NEC with bowel perforation in very depression birth weight (VLBW) infants. However, Ibáñez et al. [27] discouraged the application of SNAPPE-Ii to guide surgical intervention. In this study, we plant no significant differences of SNAP-II and SNAPPE-II scores obtained upon admission betwixt two groups. It should be noted that SNAP scores obtained at birth may indicate wellness status at birth; they cannot be used to compare severity of the disease several days later on.
Treatment of NEC unremarkably includes fasting, gastrointestinal decompression, TPN, and anti-infective measures. In the current study, NEC cases with bowel perforation had a significantly longer elapsing of fasting and required TPN and antibiotics for longer elapsing compared to those without bowel perforation. This could be related to differences in the severity of NEC and longer catamenia required for gastrointestinal functional recovery in those with bowel perforation. The college prevalence of cholestasis and EUGR in NEC cases with bowel perforation may be explained past longer periods for infants to switch from TPN to full enteral nutrition. In a long-term follow-upwards of infants with and without NEC, Pike et al. [28] constitute significantly college bloodshed and higher morbidity in intestinal and nervous arrangement in infants with NEC than those values in the grouping without NEC, a fact that is like to our findings.
The strength of our study includes the relatively complete information on demographical, clinical, and laboratory characteristics in the study population. This study has several limitations. Showtime, the electric current report was based on a single center blueprint, which may limit the generalizability of findings. Second, the sample size was relatively minor, increasing the risk for type 1 and type 2 errors. Tertiary, the handling was given up in some infants because of financial reasons, which might have influenced the study outcomes.
In conclusion, bowel perforation in premature infants with NEC is associated with lesser gestational age, lower nativity weight, apnea, mechanical ventilation, and sepsis. In addition, NEC infants with bowel perforation are at higher risk for bloodshed, and survivors may experience college risk for EUGR and cholestasis. These findings highlight the need for early on identification of these run a risk factors past close monitoring of clinical manifestations and laboratory indices in premature infants with NEC to help reduce the bowel perforation.
Acknowledgments
This research was supported by grants from the Suzhou Scientific discipline and Technology Development Project (nos. SYS201136 and SYS201440), the Natural Science Foundation Project of Jiangsu Province (no. BK20141183), Research Project of Section of Health of Jiangsu Province (no. H201316), and Research Project of the Suzhou Key Laboratory of Children's Developmental Brain Injury Prevention and Care (no. SZS201108). The authors gratefully acknowledge all members of the laboratory for sharing reagents and advice.
Abbreviations
| CHD: | Congenital centre illness |
| CRP: | C-reactive protein |
| EUGR: | Extrauterine growth restriction |
| ICH: | Intracranial hemorrhage |
| LBW: | Depression birth weight |
| NEC: | Necrotizing enterocolitis |
| RDS: | Respiratory distress syndrome |
| TPN: | Total parenteral nutrition |
| SGA: | Minor for gestational age |
| SNAP: | Score for Neonatal Acute Physiology |
| SNAPPE-2: | SNAP-Perinatal Extension-II |
| SD: | Standard deviation |
| WBC: | White claret cell count. |
Competing Interests
The authors declare that there are no competing interests.
Authors' Contributions
Lingling Yu was involved in the written report design, protocol development and implementation, data analysis, and newspaper writing. Jianmei Tian, Xingli Zhao, and Ping Cheng nerveless the clinical data; Xiaoqian Chen, Yun Yu, and Xiaochun Ding participated in clinical evaluation for NEC diagnosis. Xueping Zhu participated in the design of the study and interpretation of data and helped in drafting the paper. Zhihui Xiao participated in the design of the study and coordination and helped in drafting the paper. All authors read and approved the final paper. Lingling Yu and Jianmei Tian have equally contributed to this work.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4916290/
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